Atrial high-rate episodes predict major adverse cardio/cerebrovascular events in patients with cardiac implantable electrical devices

Abstract

Patients with atrial high-rate episodes (AHRE) have a high risk of neurologic events, although the causal role and optimal cutoff threshold of AHRE for major adverse cardio/cerebrovascular events (MACCE) are unknown. This study aimed to identify independent factors for AHRE and subsequent atrial fibrillation (AF) after documented AHRE. We enrolled 470 consecutive patients undergoing cardiac implantable electrical device (CIED) implantations. The primary endpoint was subsequent MACCE after AHRE ≥ 6 min, 6 h, and 24 h. AHRE was defined as > 175 beats per minute (bpm) (Medtronic®) or > 200 bpm (Biotronik®) lasting ≥ 30 s. Multivariate Cox regression analysis with time-dependent covariates was used to determine variables associated with independent risk of MACCE. The patients' median age was 76 year, and 126 patients (26.8%) developed AHRE ≥ 6 min, 63 (13.4%) ≥ 6 h, and 39 (8.3%) ≥ 24 h. During follow-up (median: 29 months), 142 MACCE occurred in 123 patients. Optimal AHRE cutoff value was 6 min, with highest Youden index for MACCE. AHRE ≥ 6 min ~ 24 h was independently associated with MACCE and predicted subsequent AF. Male gender, lower body mass index, or BMI, and left atrial diameter were independently associated with AHRE ≥ 6 min ~ 24 h. Patients with CIEDs who develop AHRE ≥ 6 min have an independently increased risk of MACCE. Comprehensive assessment of patients with CIEDs is warranted.

Figure 1

Development of the study cohort. Initially, 644 patients were recruited for the study; however, 174 were excluded due to a previous diagnosis of AF. Therefore, the final study cohort consisted of 470 patients, of which 123 experienced MACCE (AF atrial fibrillation, AHRE atrial high-rate episodes, MACCE major adverse cardio/cerebrovascular events; N number).

Figure 2

Receiver operating characteristic curve analysis of atrial high-rate episodes (min) in patients with CIEDs with subsequent MACCE. Atrial high-rate episodes (min): cutoff value, 6 min; sensitivity, 45.5%; specificity, 80.0%; 6 h; sensitivity, 28.0%; specificity, 91.5%; 24 h; sensitivity, 17.5%; specificity, 94.5%; area under the curve 0.633; 95% confidence intervals 0.572–0.694; p < 0.001.

Figure 3

Receiver operating characteristic curve analysis of atrial high-rate episodes (min) for subsequent atrial fibrillation. Atrial high-rate episodes (min): cutoff value, 6 min; sensitivity, 70.6%; specificity, 77.0%; 6 h; sensitivity, 44.1%; specificity, 89.0%; 24 h; sensitivity, 41.2%; specificity, 94.0%; area under the curve 0.806; 95% confidence intervals 0.722–0.889; p < 0.001.